CHILDRENS HEARTLINK CENTERS OF EXCELLENCE RECOMMENDATIONS Burke B, - - PowerPoint PPT Presentation

CHILDREN’S HEARTLINK CENTERS OF EXCELLENCE RECOMMENDATIONS

Burke B, Forst R, Li Kappe D, Malu A, Secor A McClelland RS, Dooley E June 2019

Photo: CHL

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Methods: Extensive SME Interview s & Literature Review

• Interviewed 27 Staff & Subject Matter Experts
• Reviewed published and grey literature

CHL Staff Subject Matter Experts CHL Volunteers & Partners

• Adriana Dobrzycha
• Andreas Tsakistos
• Anne Betzner
• Bistra Zheleva
• Courtney Geolat
• Jackie Boucher
• Wade Jones
• Barclay Stewart –

Operation Smile

• Beth McNairn – HVO
• Dilys Walker - PRONTO

International

• Jeffery Burns –

OpenPediatrics

• Kathy Jenkins – IQIC
• Kristin Hatcher –

Operation Smile

• Steven Hatting –

University of Washington

• Ly Phuong Anh – MEET

International

• Pam Kohler – University
• f Washington
• Robert Gertler – MEET

International

• Sarah Orth – Seattle

Children’s Hospital

• Bruce Avolio – University
• f Washington
• Jodie Miner – Swedish

Medical Center Foundation

• Bruna Cury
• David Overman
• Jeff Paurus
• Mark Lewin
• Steve Schwartz
• Sandy Staveski

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Scaling CHL’s Impact

Research and Publication Opportunities

• Research funding and

training

Strategic Opportunities

• Public-private hospital

model

• Partnership

development

• Impact metrics

Operational Opportunities

• Country selection
• Volunteer

management

• Formalizing nurse

educator program

• Phasing metrics

Increase # of Centers of Excellence Advance Thought Leadership Increase Access to Quality Care

Building on CHL’s successes to save more children with CHD

Increase # of Centers of Excellence: Operational Opportunities

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Recommendation: Expand Within Existing Countries

Prioritize scale- up in Brazil, Malaysia, and Vietnam as short time horizon

• pportunities

Consider China and India for longer time horizon

• pportunities

CHL has an opportunity to expand the reach by leveraging existing relationships and know-how within current countries

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CHD Patient Population 2030

For catchment areas of 50 partners1

Geography CHD Population

• No. Partners

India 1.5M 17 China 1.2M 12 Brazil 430,000 9 Vietnam 327,000 6 Malaysia 124,000 3 3 new LIC 205,000 3

TOTAL CHD PATIENT POPULATION

4.6M

China India Vietnam Malaysia Brazil Increase in GDP spending on healthcare Evidence for successful private-public partnerships Overall conditions for establishing training programs Evidence of UHC1, essential surgery or clinical skill development Presence of philanthropic efforts to support CHD treatment Number of medical doctors per 10,000 population2

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Identifying Enabling Country Environment

Strength of evidence Strong Moderate Weak

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Recommendation: Optimizing Volunteer Management Publicize & Subsidize Recruitment Enable Knowledge Transfer Standardize Training Curriculum

Bolstering recruitment efforts & enabling global collaboration will help CHL prepare the volunteer model to scale

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Data System to Support Operations

Metrics Tracking & Dashboards

Collect metrics data Evaluate reports on

• utcomes

Present performance dashboards

Intranet / Community

Provide forum for volunteer & partner communication Streamline

• nboarding

Share onboarding and trip related documents Host standard curriculum

Volunteer/ Partner Management

Manage volunteer and partner pipeline Manage trip logistics Store assessment and feedback responses Track follow-up communication

CRM

Manage stakeholder contacts Record and prompt stakeholder communications Track donations and grants

A single, integrated data system can help support CHL’s work in four areas

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Example Data System Solution

Context

Challenge: Scattered information made process of tracking student enrollment, retention, and

• utcomes impossible

Product Solution: Salesforce.org Used by 40K + nonprofits and education institutions globally with dynamic online support community of users and developers

• n the Power of Us Hub

Potential Cost Considerations

• Licenses
• Initial setup and training
• System admin

Case Study: Hope On A String (HOAS) operated community center in rural Haiti to empower children and adults through music and performing arts

Result

• CRM helps HOAS manage donor
• utreach and pipeline
• Student registration/attendance is now

easily trackable and HQ staff have access to real-time, actionable data on program satisfaction surveys and student

• utcomes

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Dashboards for Performance Management

Aggregate phasing metric data can provide insight into site progress

Benefits

• Help CHL internally evaluate performance of

partner sites

• Serve as tool for knowledge transfer and

transparency among volunteer and partner sites by helping them compare progress and engage in conversations about best practices

• Enable comparison of progress within a hospital
• ver time, and across hospitals
• Act as a communication tool for donors and

funding agencies

Determine the most relevant metrics to provide insight into site progress over time. Overlay progress chart for all selected sites for easy comparison and display annual information for patients seen, patients treated, and mortality rate

OVERVIEW

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Example Dashboard w ith One Site

Institut Jantung Negara | COE

PATIENTS SEEN 2018

40

PATIENTS TREATED 2018

33

MORTALITY RATE 2018

4%

Site Selection

+ Brazil + China + India

• Malaysia

Institut Jantung Negara

+ Vietnam

10 20 30 40 50 60 70 2014 2016 2018

Patien ent V Volu lume

Institut Jantung Negara 8% 9% 10% 11% 12% 13% 14% 15% 16% 2014 2015 2016 2017 2018 2019

Postope perativ ive I Infectio ion R Rates es

Institut Jantung Negara 3% 4% 5% 6% 7% 8% 2014 2016 2018

Infant M t Morta tality R ty Rate tes

Institut Jantung Negara

* Randomly generated data to convey idea

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Example Dashboard w ith Multiple Sites

Hospital de Messejana | Phase 1 Institut Jantung Negara | COE Vietnam National Children’s Hospital | Phase 1

PATIENTS SEEN 2018

95

PATIENTS TREATED 2018

76

MORTALITY RATE 2018

5.7%

Site Selection

• Brazil

Hospital de Messejana Hospital da Crianca e Maternidade

+ China + India

• Malaysia

Institut Jantung Negara

• Vietnam

Vietnam National Children’s Hospital Nhi Dong 1 Kien Giang General Hospital

10 20 30 40 50 60 70 2014 2016 2018

Patien ent V Volu lume

Institut Jantung Negara Hospital de Messejana Vietnam National Childeren's Hospital 8% 10% 12% 14% 16% 18% 2014 2015 2016 2017 2018 2019

Postope perativ ive I Infectio ion R Rates es

Institut Jantung Negara Hospital de Messejana Vietnam National Childeren's Hospital 3% 4% 5% 6% 7% 8% 2014 2016 2018

Infant M t Morta tality R ty Rate tes

Institut Jantung Negara Hospital de Messejana Vietnam National Childeren's Hospital

* Randomly generated data to convey idea

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Recommendation: Nurse Educators Are Vital For Success

Formalize nurse educator program Hire a nurse educator at CHL headquarters Provide support for hiring nurse educators at partner sites

Nurse educators create a sustainable way to improve competency of nursing staff and reduce turnover

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Nurse Educators Are Highly Cost Effective

A case study of nurse educators cost-effectiveness in the pediatric oncology nursing education programs across 7 Latin American countries

Cost comparison results1, 2:

• Short lecture series: 1-2 week lecture series at

partner site = $4,415 / nurse

• Expanded lecture series: 12-week lecture series

at partner site = $5,190 / nurse

• Residential training: 3-month residential training

= $6,554 / nurse

• Nurse educator: direct costs of salary and

benefits of a full-time nurse educator providing education to 49 nurses 01/07-09/09 = $244/nurse

• The study was scaled to 13 nurse educators

across 7 countries in Latin America

$4,415.00 $5,190.00 $6,554.00 $244 $- $1,000.00 $2,000.00 $3,000.00 $4,000.00 $5,000.00 $6,000.00 $7,000.00 Short Lecture Series Expanded Lecture Series Resident Training Nurse Educator

Average Educational Cost per Pediatric Oncology Nurse by Education Model

Key Factors For Hiring Nurse Educators

AT CHL HEADQUARTERS AT PARTNER SITES Key Responsibilities

• Develop and maintain curriculum for
• verall nurse education program
• Facilitate development and

implementation of PCICU quality control projects

• Coordinate data collection from partner

sites and provide data analysis

• Customize and implement nurse

education curriculum

• Manage PCICU quality control projects
• Perform data collection

Qualifications

• Master’s Degree1
• International clinical and administrative

experience

• Master’s Degree1
• Clinical experience
• Local

Profile Example

• Sandra Staveski, PhD, RN, PNP
• Jeff Paurus, MS
• Bruna Curry, MS

Accelerating organization change through formalizing nurse educator program

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Recommendation: Standardize Phasing

Link benchmarks for success to indicators and use IQIC to support clinical data collection and reporting Implement standard annual survey for partners Consider one set

• f core indicators

for all sites and adoption of a competency area approach for assessing progress Long-term: develop and integrate quantitative indicators for non-clinical benchmarks

Implement new 15-question annual survey to enable apple to apple comparison of growth between and across sites

Core Indicators by Competency Area

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Competency area approach uses one set of core metrics across all sites and allows progress to be determined by competency area

Clinical Care Multidisciplinary Approach Regional Leader in CHD

• Number of cases, disaggregated by

gender

• Range of services provided
• In-hospital mortality
• Development and use of QI system
• Development and use of infection

prevention and monitoring system

• Infection rate
• Mortality within 30 days
• Number and proportion of patient

families who receive counseling and education intervention

• Actions taken to support sustainability
• f QI system
• Develop team communication plan to

support a team-based approach to care

• Use of communication plan and/or change

management tool for communication

• Actions taken or outcomes attributed to

adoption of multidisciplinary approach

• Explore potential partnerships in region with

MoH and primary health care systems

• Actions taken to show commitment to clinical

research

• Implement continuing education program for

all practitioners at partner hospital

• Number of publications and poster

presentations on research or lessons learned, disaggregate by formal/informal

• Actions taken to show commitment to

regional training efforts

• Number of trainings and participants

Black text: available from IQIC Blue text: collected through annual survey or internal partner activity tracking spreadsheet

Potential Frameworks for Assessing Progress Against Core Indicator Targets

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Clinical Care Multidisciplinary Approach Regional Leader in CHD

• More than 100 cases per year
• In-hospital mortality baseline determined
• QI system is developed
• Infection prevention and monitoring system is developed
• Develop team communication plan to

guide a team-based approach to care

• Explored potential partnerships in region

with MoH and primary health care systems

• Baseline for mortality within 30 days is established
• QI system is used to improve clinical outcomes
• Infection prevention and monitoring system data is used to

improve clinical outcomes

• Infection rate is less than X%
• Mortality less than 10%
• The proportion of patient families who receive counseling and

education intervention is greater than X%

• Evidence of communication plan and/or

change management tool used to support multidisciplinary team communication

• Significant actions taken to show

commitment to clinical research

• Implementation of continuing education

program for all practitioners at partner hospital

• Significant actions taken to support sustainability of QI system
• Infection rate is less than X%
• Mortality less than 4%
• More than 250 cases per year
• Full range of services provided
• The proportion of patient families who receive counseling and

education intervention is greater than X%

• Evidence of communication plan and/or

change management tool used to support multidisciplinary team communication

• Significant actions taken or outcomes

attributed to adoption of multidisciplinary approach

• Number of publications and poster

presentations on research or lessons learned, disaggregate by formal/informal

• Significant actions taken to show

commitment to regional training efforts

• Number of trainings and participants

Expert Refine Learn

Incremental wins as center builds capacity

Black text: available from IQIC Blue text: collected through annual survey or internal partner activity tracking spreadsheet

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Recommendation: Impact Metrics

Use RE-AIM framework to evaluate and document impact Consider long-term impact metrics, such as postoperative quality of life & reintegration into communities

Consider adopting new metrics and the RE-AIM framework to convey CHL’s impact on CHD

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Recommendation: Expanding Impact Through Public-Private Partners

The public-private hybrid hospital model can solve capacity and quality issues, benefiting both sectors simultaneously Public Hospital Private Hospital

Pursue public-private hospital partnerships to increase access to quality care

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Cross-leverage strengths:

• Private sector: capacity building,

clinical expertise, high quality care

• Public sector: access to patients,

national insurance schemes Three most common PPP business models:

• 1. Infrastructure-based model
• 2. Discrete clinical services model
• 3. Integrated/Hybrid PPP model

Public-Private Partnerships

Capture private sector capital and expertise to improve provision of public health services

Potential for future PPPs across the healthcare continuum1

Preventative Care Primary Care Immediate Care Specialist Care Diagnostics Ancillary Care Emergency Care Inpatient Care Rehabilitation Care Long-term Care Skilled Nursing Home Health End of Life Care

Future Opportunities Focus of most healthcare PPPs today Future Opportunities

Extension

• f care

Extension

• f care

Healthcare Continuum

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Hybrid Public-Private Model Example: Mexico

“The advantages of each of the different sectors were exploited to create a better model.” –Dr. Alexis Palacios-Macedo INP-ABC-TCH Partnership

• Care provided at ABC
• MOH agreed to fund 40 positions -

multidisciplinary team provided by INP

• Patients referred from INP and other public

hospitals

• Surgery conducted at INP or ABC

depending on bed availability

• 447 patients (379 from public 68 from

private) have undergone surgery

• Overall mortality reduced from 15% in

2012 to 6.6% in 2018

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Deeper Look at INP-ABC-TCH Model

Notes from a stakeholder interview with Dr. Alexis Palacios-Macedo & Blanca del Valle Perochena Challenges

• Insufficient volume of private

patients

• High-income patients seeking care

in another country

• Weak referral networks
• Patients loyalty rests with doctors

instead of institutions Success Factors

• Seguro Popular covers treatment in

private hospitals

• ABC cross-subsidizes public care

with portion of profits

• Kardias Foundation support
• Twinning partnership with TCH
• Dedicated, full-time team
• Joint Commission certification

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Hybrid Public-Private Model Example: Vietnam

Vietnam’s enabling environment and buy-in to a hybrid hospital program offers a promising

• pportunity for CHL

Gia An 115 Hospital (Established 2018)

• First hospital established under PPP model

Approved by People’s Committee of HCMC to relieve patient overload at public hospitals

• Engages specialists form state run People’s

Hospital 115 to work at private Gia An 115 to ensure provision of specialized services

• Grand opening ceremony campaign by

doctors and nurses raised $27 thousand for “Healing Heart Beat” project to provide treatment for CHD for low-income families

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Hybrid Model Facilitators & Barriers

Facilitators and barriers to the success of public-private hybrid hospital partnerships were identified as common themes in country case studies Barriers

Political

• Partnerships subject to changing political whims
• Trust deficit
• Labor union rules that limit work schedule

flexibility

• Insufficient salaries of public providers

Organizational

• Not enough private patient-flow for cross-

subsidy sustainability

• Mismatched organizational styles and differing

priorities

• Lack of sustainable funding source

Facilitators

Political

• Enabling regulatory and political environment
• National public health insurance coverage

Organizational

• Sufficient patient volume and provider expertise
• Sufficient volume of privately insured patients
• Demand-side control factors
• Teams solely dedicated to hybrid program
• Internal champions
• Philanthropic support

Hire/Expand Role of In-Country Managers

Role & Responsibilities

• Advocate for issues that support CHD care,

such as expansion of insurance to include CHD services or government programs for early detection

• Develop relationships with local

philanthropists and organizations to explore local fundraising opportunities

• As M&E efforts expand, provide support to

partner hospitals for data capture, management, and reporting, particularly for indicators outside of IQIC

Profile

• Local connections with MoH/government
• fficials
• Policy/advocacy experience
• Fundraising experience
• Monitoring and evaluation experience

Example Blanca del Valle Perochena

• Vice President of the Board of Directors of

Kardias, a foundation for children with heart disease

• Supporting Kardias to professionalize and

develop a strategic plan

In-country managers can lead country-level advocacy, local fundraising, and can support data collection

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Recommendation: Partnerships for Sustainability and Influence

Medical & nursing associations to influence relevant national policies NGOs to expand CHL’s reach Corporate giving programs to diversify funding Local philanthropists to diversify funding and gain influence

Partnerships can help CHL gain access to influential decision-makers and raise its profile as the preeminent global CHD thought leader

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Recommendation: Supporting the Research Agenda

Opportunity to increase research efforts through CHL Fellowship & participating in existing research focused fellowships

Focus on Research Leverage Existing Fellowships

Consider public speaking

• pportunities to

bring attention to CHD and highlight CHL’s work

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Leverage Students & Existing Fellow ships

Opportunities to support research efforts through existing research focused fellowships & public health students

Existing fellowship opportunities to support junior researchers

Fogarty funding

• Funds US fellows to go to partner hospitals

to conduct independent research and to support broader research efforts at the hospital Northern/Pacific Global Health Fellows

• Fellows pursue a wide range of research
• pportunities including into cardiovascular
• disease. Researchers are paired with a

team of mentors to provide support over the course of the fellowship

Work with public health graduate students

• Inexpensive way for CHL to support

research and/or M&E efforts

• MPH students usually need to complete a

practicum

• PhD students are looking for dissertation

projects

• Students are looking for real world

experience and on-going projects

Conclusion

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Implementing Recommendations

Building on CHL’s success will have significant organizational implications in a few areas

Level of Organizational Systems Level of Delegation of Autonomy

High Low Low High

Staffing

• Expand volunteer pipeline
• Expanded roles of country directors
• Nurse educators – CHL HQ and at partner

hospitals

• Fundraising specialists

Knowledge Sharing

• CRM
• Develop standardized core curriculum
• Integrated communication for volunteers

Partnerships

• Extend partnership strategy

Phasing

• Standardize core metrics
• Develop and conduct standardized annual

survey for all partner hospitals